MEDICARE: MR. CHARLES STEPHEN WILLIS M.MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	1800	TX
2	101YP2500X	Professional Counselor	9937	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2617LC	OTHER		BLUECROSS/BLUESHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720160146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES STEPHEN WILLIS M.MFT

Provider Business Mailing Address
First Line	:	PO BOX 3711
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79604-3711
Country	:	US
Telephone Number	:	325-437-1001
Fax Number	:	325-437-1005

Provider Business Practice Location Address
First Line	:	500 CHESTNUT ST
Second Line	:	STE. 1001
City	:	ABILENE
State	:	TX
Zip	:	79602-1453
Country	:	US
Telephone Number	:	325-437-1001
Fax Number	:	325-437-1005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	12/09/2021

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